A 28yo Semi-Professional Volleyball player with a complaint of Right-Sided Shoulder Pain.

Case Report:

Author

Marco Rosario De Vito Director/Senior Physiotherapist at Marco Physio-London Physiotherapy Clinics.

 QUALIFICATION:

TWO DEGREES IN PHYSIOTHERAPY AND SPORT SCIENCE AT KING'S COLLEGE IN LONDON.POSTGRADUATE IN ORTHOPEDIC MEDICINE AND SPORT MEDICINE AT QUEEN MARY IN LONDON. MARCO BELIEVES IN PROVIDING EVIDENCE BASED AND EFFECTIVE TREATMENT TECHNIQUES. OUR PHYSIOTHERAPISTS ARE EXPERT IN SPORTS REHABILITATION AND HAVE TREATED SPORT RELATED INJURIES LIKE NECK/BACK PAIN, SHOULDER PAIN, KNEE PAIN, GROIN PAIN, TENNIS ELBOW, ANKLE SPRAIN.

Canary Wharf:   94 Milligan Street, Westferry Studios, London, E14 8AS.        
Tel: 0207 005 0278   Mob: 07950 558 127. http://marcophysio.com/

Victoria:  Portland House Bressenden Place Room 203, 2nd floor, London, SW1E 5RS
Tel: 0207 005 0278   Mob: 07950 558 127 http://marcophysio.com/

 ABSTRACT

The patient main complaint was the inability of continuing playing volleyball at a semi-professional level. A 28-year-old semi-professional volleyball player with a 5 week history of right anterior-superior shoulder pain aggravated by performing volleyball “spike”, free weights chest press, with discomfort at full rom in flexion, resisted abduction and external rotation, with reverse scapulohumeral rhythm, positive on impingement tests.

Risk Factors and sports specific aspects

Shoulder injuries amongst volleyball athletes are mainly reported to result from overuse possibly leading to rotator cuff tendinitis, coracoacromial impingement and glenohumeral joint instability.  In an epidemiological study amongst 295 volleyball players, Aagaard and colleagues (1) reported 286 injuries with an incidence of 4.2 injuries every 100 hours of playing.  The most frequent injuries were acute injuries located in the ankle and finger and overuse injuries in the knee and shoulder, which occurred mostly during blocking and spiking.


The risk factors associated with the recurrence of shoulder pain are linked to:

• Overuse during training
• Poor shoulder mobility
• Muscle imbalance, specifically between internal and external rotators
• Muscle weakness
• Scapular dyskinesis

The implication for the patient was to modify his training regime and stop his participation to games.  It is paramount to diagnose the injury in time and produce an appropriate treatment plan with a specific gradual return to training.

Examination

Inspection

• Static scapular malposition compared to the non-affected side.
• Dropped scapula due to scapular protraction, lateral displacement and abduction.
• Moderate scoliosis with right thoracic and left lumbar curvatures.
• Anteriorly, apparent inferior position of the lateral clavicle due to scapular protraction.

ROM

• Reverse scapulohumeral rhythm with shoulder elevation and excessive scapular lateral tilt after 60° of abduction
• Full flexion with increased shoulder elevation after 75°
• Full external rotation with discomfort at the end of range

Resisted tests

• Abduction combined with external rotation against resistance was painful (VAS 7/10) and weaker than left side
• External rotation and abduction when tested singularly did not reproduce symptoms
• Scapular retraction with rhomboids activation was weaker on the right side and position could not be maintained for 10 seconds

Palpation

• Tenderness on the coracoid medial aspect, at the point of insertion of the pectoralis minor tendon.
• Tenderness on the superior scapular border at the attachment of the elevator scapulae
• Acromioclavicular ligament discomfort

Scapular assistance test

• Laterally and upward manual assistance of the inferior medial scapular border to simulate the serratus anterior/lower trapezius portion of the elevation force couple.
• Discomfort at the end of range was not present when technique applied

Other

• Empty-can test for rotator cuff integrity: mild discomfort.
• Neer test for impingement: positive at full internal rotation
• Kennedy-Hawkins test for impingement: positive.
• Acromioclavicular shear test: positive

Rehabilitation

Rehabilitation is based on a proximal to distal regain of motion, control, and strength.

SMART GOALS

Proximal Scapular Control And Strength                                   35%

Antagonist Musculature Increase In Flexibility                           50%

Correction Of Postural Dysfunction                                           35%

Decreasing Symptoms                                                              40%

Rehabilitation Plan

• Avoidance of painful exacerbating movements (volleyball spike, chest press) and fatigue of the scapula-humeral/thoracic muscles.
• Initiation of closed kinetic chain (CKC) activities in order to reproduce or provide proprioceptive stimulation to joint mechanoreceptors which helps to reorganize and re-establish normal muscle firing patterns.
• CKC activities can include weight shifts, scapular clock, rhythmic ball oscillations and wall-push ups.

• Inclusion of activities which involve using of hip and trunk musculature (mass movement patterns) such as trunk strengthening: abdominal crunches and/or prone upper/lower extremities opposition for para-spinals; trunk extension with lateral rotation facilitates scapular retraction.
• Scapular retractions combined with massage to reduce contracture of coracoid based muscles.
• Myofascial release near anterior clavicle or delto-pectoral triangle
• Manual stretching of scalenes, elevator scapulae, pectoralis minor.
• “Sleeper” stretches to stretch posterior capsule and posterior rotator cuff muscles
•  Interval volleyball training can commence including aerobic training, ball activity with partners, sprinting and change in direction.

Recovery Phase (3 –7 weeks)

SMART GOALS
Proximal scapular control and strength                 70%
Antagonist musculature increase in flexibility        75%
Correction of postural dysfunction                         60%
Decreasing symptoms                                            70%
Return to volleyball training                                     50%

• Begin with concentric/eccentric contractions.
• Standing external rotation (ER) with theraband (towel roll under axilla cueing patient to avoid trunk rotation); side lying ER

• Serratus anterior punch/press into wall with pillow or deflated ball (standing, arm neutral at side elbow in 90° of flexion). Progression to arm at or just below 90°
•  Seated rows emphasizing setting of the scapula prior to each repetition, finishing each set in retraction
• Lower/mid trapezius activation in prone with progression to different upper limb positions.
• Interval volleyball training can commence including aerobic training, ball  activity with partners, sprinting and change in direction.

Maintenance Phase (7 – 10 weeks)

SMART GOALS:
Proximal scapular control and strength              90%
Antagonist musculature increase in flexibility      90%
Correction of postural dysfunction                       80%
Decreasing the symptoms                                   95%
Return to volleyball training                                 100%

At this stage, the patient must have good scapular control and motion throughout range of shoulder motion in order to progress to full athletic activities.

• Ply metric with medicine ball to dynamically challenge scapular stabilizers. The weight of the ball provides an eccentric stretch, which is then converted to a concentric contraction. Progress to unilateral throwing of smaller weighted medicine balls or bilateral overhead ball toss against a spring trampoline.
• Modified push-ups.

• Chair push ups or seated dips.

• ‘Scaption” arm in 30 – 45° abduction.
• Rhythmic stabilization of rotator cuff muscles.
• Return to volleyball training, with gradual return to spiking ad serving and interval competitive matches.

Evidence base

Strengthening Training:

Shoulder muscle imbalance and weakness, low shoulder rotator muscle strength ratios and weak external rotators are possible shoulder injury risk factors for overhead athletes. In the dominant arm, the volleyball players had significantly higher concentric peak torque of the internal and external rotators at both velocities, and significantly higher eccentric peak torque of the shoulder internal and external rotators than the controls. In a similar study by Forthomme and colleagues (4), spike velocity correlated significantly with strength performance of the dominant shoulder rotator muscles.  In acceleration, however, these muscles behaved independently; activity of the teres minor remained high, whereas the activity of the infraspinatus declined. The anterior wall muscles functioned to decelerate the humerus during cocking and acted as internal rotators during acceleration. Muscle activities recorded for the serve followed similar patterns as those seen for the spike, but with lower amplitudes.  In the specific clinical scenario presented in this report, a strength-training regime was designed for the patient taking into account his needs.  Weakness of the external/internal rotator muscles and scapular stabilizers was addressed through a strengthening programme incorporating concentric and eccentric activation patterns and was progressed to include sport specific drills.

Scapular Stabilizers Training

Scapular malposition is thought to be related to shoulder impingement by narrowing of the subachromial space.  Scapular dyskinesis was also associated with excessive protraction and decreased cocking and elevation, which can effectively alter volleyball specific biomechanics. The athlete in this case scenario presented a scapula infera with lateral displacement.  A specific training regime was designed to retrain scapular stabilizers in an isometric fashion and was progressed to include concentric and eccentric activation patterns with sport specific drills.  Since the scapula plays a vital role in the volleyball spike as it acts as a stable base for origin of the muscles that control arm movement and provide glenohumeral compression, scapula position and control training is paramount during rehabilitation and as part of a preventative exercise regime. Rehabilitation protocol aimed to restore scapular musculature balance produced significant changes of glenohumeral internal rotation, increase in rotator muscle strength and decrease in pain scores, which seem to confirm the role of a proper scapular position for an optimal length–tension relationship of the RC muscles.

References

• AagaardH., ScaveniusM.,JørgensenU.  “An Epidemiological Analysis of the Injury Pattern in Indoor and in Beach Volleyball”.  Int J Sports Med 1997; 18(3): 217-221.
• Wank, H. and Cochrane, T.  “Mobility impairment, muscle imbalance, muscle weakness, scapular asymmetry and shoulder injury in elite volleyball athletes”.  Journal of sports medicine and physical fitness, 2001; 41; 401-403.
• Alfredson, H., Pietila, T., Lorentzon, R.  “Concentric and eccentric shoulder and elbow muscle strength in female volleyball players and non-active females”.  Scandinavian journal of science and sports, 1998, vol. 8 (1), 5, 265-270.
• Forthomme, P.,  Croisier, J., Ciccarone, G., and Cloes, M.  “Factors Correlated With Volleyball Spike Velocity”.  Am J Sports Med October 2005 vol. 33 no. 10 1513-1519.
• Rokito, A., Jobe, J., Pink, M., Perry, J. and Brault, M.  “Electromyographic analysis of shoulder function during the volleyball serve and spike.”  Journal of elbow and shoulder surgery, 1998, 7 (1), 256-263
• Niederbracht, Y., Shim, A., Sloniger, M., Paternostro-Bayles, M., Short, T.  “Effects of a Shoulder Injury Prevention Strength Training Program on Eccentric External Rotator Muscle Strength and Glenohumeral Joint Imbalance in Female Overhead Activity Athletes”.   Journal of Strength & Conditioning Research, 2008, 22 - Issue 1, 140-145.
• Yildiz, Y., Aydin, T., Sekir, T., Kiralp, M., Hazneci, B., Kalyon, A.  “Shoulder terminal range eccentric antagonist/concentric agonist strength ratios in overhead athletes.”   Scandinavian Journal of Medicine & Science in Sports, 2006, 16 (3), 174-180.
• Burkhart, S., Morgan, C., Kibler, W.  “The disabled throwing shoulder: spectrum of pathology.  Part III: the SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation.”  Arthroscopy: the journal of arthroscopic and related surgery, 2003, 19 (6), 641-661.
• Kugle, A., Kruger-franke, M., Reininger, S., Trouillier, H., Rosemeyer, B.  “Muscular imbalance and shoulder pain in volleyball attackers.”  British journal of sports medicine, 1996, 30, 256-259.
• Merolla, G., De Santis, E., Sperling, J., Campi, F., Paladini, F., Porcellini, G.  “Infraspinatus strength assessment before and after scapular muscles rehabilitation in professional volleyball players with scapular dyskinesis.”  Journal of shoulder and elbow surgery, 2010, 19 (8), 1256-1264.
• Reeser, J, Verhagen, E., Briner, W., Askeland, T., Bahr, R.  “Strategies for the prevention of volleyball related injuries”.  British journal of sports medicine, 2006, 40, 594-600.
• Wang, H. and Cochrane, T.  “A descriptive epidemiological study of shoulder injury in top level English male volleyball players”.  International journal sports medicine, 2001, 22 (2), 159-163.
• Sandow, M. and Illic, J.  “Suprascapular nerve rotator cuff compression syndrome in volleyball players.”  Journal of shoulder and elbow surgery, 1998, 7 (5), 516-521.
• Ferretti, A., De Carli, A., Fontana, M.  “Injury of the suprascapular nerve at the spinoglenoid notch: the natural history of infraspinatus atrophy in volleyball players.”  American orthopaedic society for sports, 1997, 23^rd annual meeting.
• Ellenbecker, T.  “Shoulder rehabilitation”: non operative treatment.”  Thieme medical publishers, 2006.